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Can Our Commercialized Health Care System Contain Ebola?

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Yves here. I’m not one to fan Ebola fears. In fact, I’m a bit loath to give it the prominence in Links that I am, given the small number of cases in the US and in the world ex the afflicted parts of Africa. While the mortality rate is high, it’s not all that infectious. You are still more at risk from dying by virtue of driving (if you drive) than you are of dying from Ebola or terrorism.

However, whether or not Ebola morphs into a more virulent version, concern about it is legitimate, if for no other reason than that the US healthcare system is neither willing nor able to cope well with flareups of deadly diseases. Virologists have been warning for some time that the outbreak of a pandemic is almost inevitable. Hence, for instance, the concern about outbreaks of various respiratory diseases, like SARS, in recent years.

Yet despite the view among experts that a modern plague of some sort is a matter of when, not if, the commercialized practice of medicine in the US has rendered the healthcare establishment particularly ill-equipped to deal with it. This is yet another example of crapification, but with far more dire consequences.

By Roy Poses, MD, Clinical Associate Professor of Medicine at Brown University, and the President of FIRM – the Foundation for Integrity and Responsibility in Medicine. Cross posted from the Health Care Renewal website

Not to bury the lede, I think it can, but it will be a lot harder than the talking heads on television predict.

I have been writing about health care dysfunction since 2003.  Lots of US politicians would have us believe we have the best health care system in the world (e.g., House of Representatives Speaker John Boehner (R-Ohio), here),   Much of the commentary on Ebola also seems based on this “best health care system in the world” notion.  For example, in an interview today (5 October, 2014) on Meet the Press, Dan Pfieffer, “senior White House adviser,” said

There is no country in the world better prepared than the United States to deal with this. We have the best public health infrastructure and the best doctors in the world.

However, at least the statistics say compared to other developed countries, US processes and outcomes are at best
mediocre using the best of some admittedly flawed metrics (look here), yet our costs are much higher than those of comparable countries.  Furthermore, on Health Care Renewal we have been connecting the dots among severe problems with cost, quality and access on one hand, and huge problems with concentration and abuse of power, enabled by leadership of health care organizations that is ill-informed, incompetent, unsympathetic or hostile to health care professionals’ values, self-interested, conflicted, dishonest, or even corrupt and governance that fails to foster transparency, accountability, ethics and honesty.

Thus there is reason to worry that it will be harder than many expect for the US to deal with Ebola.  There is already some evidence that some of the sorts of problems we have been discussing for years made it harder for the US to cope with even the so far limited incursion of Ebola.

Financialization of Pharmaceutical and Biotechnology Companies

George W Merck famously said,
 

We try never to forget that medicine is for the people. It is not for the profits. The profits follow, and if we have remembered that, they have never failed to appear. The better we have remembered it, the larger they have been.

In the pharmaceutical industry, the era of George W Merck is over.  The failure to have access to an effective Ebola virus vaccine exemplifies how things have changed.

If we were to have an effective Ebola virus vaccine, we could have likely used it to vaccinate health care workers and contacts of infected patients and likely thus halt the epidemic early.

A story in Modern Healthcare suggested that now many of the big experts on Ebola and public health are concluding having a vaccine available would be very helpful,

As West Africa’s Ebola outbreak continues to rage, some experts are coming to the conclusion that it may take large amounts of vaccines and maybe even drugs — all still experimental and in short supply — to bring the outbreak under control.

Specifically,

It is conceivable that this epidemic will not turn around even if we pour resources into it. It may just keep going and going and it might require a vaccine,’ Dr. Anthony Fauci, director of the U.S. National Institute for Allergy and Infectious Diseases, told The Canadian Press in an interview.

The main reason we do not yet have such a vaccine does not appear to be scientific, but economic.

Here we posted discussion of arguments that pharmaceutical and biotechnology companies up to now have been uninterested in developing Ebola vaccines because they did not anticipate that such vaccines would produce a lot of revenue.  About one month ago, the Independent ran yet another story about an Ebola expert who believed this was the main reason for the lack of effective vaccine development up to now.

The scientist leading Britain’s response to the Ebola pandemic has launched a devastating attack on ‘Big Pharma’, accusing drugs giants including GlaxoSmithKline (GSK), Sanofi, Merck and Pfizer of failing to manufacture a vaccine, not because it was impossible, but because there was ‘no business case’.

West Africa’s Ebola outbreak, which has now claimed well over 2,000 lives, could have been ‘nipped in the bud’, if a vaccine had been developed and stockpiled sooner – a feat that would likely have been ‘do-able’, said Professor Adrian Hill of Oxford University.

The US health care system is now heavily commercialized.  Health care
corporations, including pharmaceutical and biotechnology companies, are
often lead by generic managers who subscribe to the business school dogma of the “shareholder value theory,” which seems to translate into putting short-term revenues ahead of all other goals.  Thus they have been “financialized.”  At least in the pharmaceutical and biotechnology sector, such financialization appears to now be global. 

It may now be too late to contain this particular Ebola virus epidemic using a vaccine.  But unless we change how decisions are made about vaccine development, and end the dominance of financialization over drug and vaccine development, we may not be able to control the next deadly epidemic using vaccines either.

Generic Management Deluded by Business School Dogma

On 2 October, 2014, InformaticsMD posted on Health Care Renewal his speculation that the Ebola patient now hospitalized in Dallas was not identified on his first emergency department visit to Texas Health Presbyterian hospital even though a nurse apparently found out he had recently traveled from Liberia because of problems with how the hospital’s electronic health record (EHR) transmitted or displayed this information.  This supposition was later apparently confirmed, but then the hospital system CEO retracted this explanation, leaving the reason he was sent home from the ED, thus risking infection of more contacts, unclear (see this post).

I now speculate that the larger reason for the problems the hospital had and is having both handling this patient, and explaining how it handled the patient is hospital leadership by generic managers who do not really understand the relevant health care issues.

Mr Barclay E Berden, the CEO of Texas Health Resources, has had a long career in hospital management.  However, his most advanced degree was “a master’s degree in business administration with a specialization in hospital administration from the University of Chicago Graduate School of Business.”   His official biography suggests that he has no direct experience or training in medicine, health care, or biological sciences.  Nonetheless, when he became CEO this year, according to Modern HealthCare, the chairperson of the hospital system board thought he was fully qualified,

He brings a well-rounded perspective and unique leadership strengths to the CEO position,’ board Chair Anne Bass said in a news release. ‘At the same time, he represents stability and continuity that will be critical to advancing our strategy as we confront the challenges of a rapidly changing healthcare environment.’

Nonetheless, the hospital systems seems to have had trouble confronting the challenges of the change in environment due to Ebola.  Also, according to a very recent story in the Dallas Morning News, there have been performance issues at Texas Health Resource hospitals, and specifically at Texas Health Presbyterian,

Texas Health Presbyterian Hospital — under fire for releasing a Liberian man who later turned out to have the Ebola virus — has lagged behind its peers on emergency room care and lost some federal funds the past three years because it had high discharge rates of patients who later had to return for treatment.

The hospital scored significantly worse than the state and national averages in five of six emergency care indicators, with emergency room wait times twice as long as the averages, according to data from the U.S. Centers for Medicare & Medicaid Services.

The hospital also was the most penalized in Dallas under a three-year program designed to reduce the number of patients readmitted for care, according to the data.

The delays in patient treatment in the emergency room, in particular, raise important questions about Presbyterian’s emergency care, said Dr. Ashish Jha, a professor at Harvard University’s School of Public Health and a practicing general internist.

In 1988, Alain Enthoven advocated in Theory and Practice of Managed Competition in Health Care Finance, a book published in the Netherlands, that to decrease health care costs it would be necessary to break up the “physicians’ guild” and replace leadership by clinicians with leadership by managers (see 2006 post here).

Thus from 1983 to 2000, the number of managers working in the US health care system grew 726%, while the number of physicians grew 39%, so the manager/physician ratio went from roughly one to six to one to one (see 2005 post here). As we noted here, the growth continued, so there are now 10 managers for every US physician. 

We have frequently discussed how generic managers in charge of health care organizations may follow business-school dogma at the expense of patients’ and the public’s health.  In particular, they may also prioritize short-term revenue ahead of all other concerns, and hence may favor high-technology and procedural care, often performed electively, ahead of the the less glamorous and remunerative parts of health care, e.g., ED care of poor, uninsured, febrile patients.

Unfortunately, much of the country’s efforts to ward off Ebola are likely to be lead by generic managers who may have little understanding of epidemiology, public health or virology, and little understanding of the state of health care at the sharp end.  So unfortunately I expect continuing “glitches,” or worse.  Hopefully, the country, although not every single one of its inhabitants, will survive them.  Then we need to seriously reflect on the wisdom of handing control of health care over to generic managers, rather than health care professionals. 

Commercialization of Health Care Leading to Neglect of Routine Acute Care and Public Health 

Just as national politicians and government leaders have repeated the meme of the US health care system being “the best in the world,” now that Ebola has come to Texas, state leaders have sung the same song.  For example, an editorial in the Baltimore Sun quoted the state health commissioner,

‘This is not West Africa,’ Texas health commissioner Dr. David Lakey said Wednesday at a news conference designed to dispel Texans’ (and Americans’) fear of an Ebola outbreak after a man there was diagnosed with the disease. ‘This is a very sophisticated city, a very sophisticated hospital.’

The Texas Tribune ran a story produced in cooperation with Kaiser Health saying,

At a Wednesday press conference to discuss the Ebola case, Gov. Rick Perry said he was confident in the state’s preparedness. ‘There are few places in the world better equipped to meet the challenge that is posed in this case,’ he said. ‘We have the health care professionals and the institutions that are second to none.’

However, another Dallas Morning News story recounted various problems in the public health response to the Dallas Ebola patient, including,

Delay in blood testing
After Duncan was admitted to the hospital, health officials waited nearly two days to test his blood for the Ebola virus. This may have delayed containment of people who had contact with him.

Slow containment and cleanup
Health officials left some of Duncan’s close contacts in the apartment where soiled linens and towels that he had used remained.

Failure to avoid contact with emergency workers
Ambulance workers and sheriff’s deputies are among those being monitored.

So, there is reason to suspect that the public health system in Texas may not exactly be the best in the world.  In fact, there seem to be systemic problems with public health in Texas that the Ebola scare is bringing to increased public notice.  The Texas Tribune/ Kaiser story went on to explain that in Texas, a state in which distrust of central government is great, and confidence in the private sector is high, public health is both decentralized and often poorly funded,

‘We don’t really have a unifying construct for public health in Texas that’s comprehensive,’ said Dr. Eduardo Sanchez, the former commissioner of the Texas Department of State Health Services (DSHS) and current chairman of the Texas Public Health Coalition. ‘The system is not as connected as it could be.’

Furthermore,

But public health experts argue that the state’s response system is ‘fragmented’ and vulnerable to local budget cuts, which they say could hamper crisis-response efforts in the case of diseases that are more easily transmitted.

Texas’ local health departments, which provide services like immunizations and disaster response planning, operate autonomously and are funded primarily by local taxes but may be supplemented by state and federal grants. Because local health departments are not held to a single standard, their services and budgets vary tremendously around the state.

A report critical of the state’s public health system, prepared by the Sunset Advisory Commission, found that ‘the roles and responsibilities of DSHS and local health departments remain undefined.’ The Sunset Commission is tasked with highlighting inefficiencies at state agencies and recommending legislative action.

‘A ‘local health department’ can be a few staff conducting restaurant inspections and animal control duties, or a large agency directing sophisticated disease surveillance, operating a public health laboratory and providing direct services to citizens,’ according to the report.>

Some public health officials have criticized the state’s model as disjointed. Many local health departments operate independently; however, if local budget cuts to a public health department force it to discontinue a health service, DSHS is often required to step in and take responsibility for that service. The state is then left to foot the bill.

‘In the event of a public health emergency … the resources necessary to adequately respond to that are not all in the control of the health department,’ Sanchez said. ‘You have to have the money and the authority — whether it’s informal or formal — to actually lead a response and take care of business.’

Local entities have slashed funding for health departments in recent years, said Catherine Troisi, an epidemiologist at the University of Texas School of Public Health in Houston. Thirty-six percent of local health departments in Texas laid off staff as a result of budget cuts between 2008 and 2013, according to the National Association of County and City Health Officials.

‘Public health is politics,’ Troisi said.

In the US, we have pushed commercialization of health, health care and public health.  Much of our health insurance is provided by for-profit corporations.  Some of our hospitals and other organizations that provide direct patient care are for-profit.  As we noted above, most of our health care organizations are now run in a “business-like” manner by managers trained in business, but not necessarily in health care or biological science.  The thus revenue-focused health care system has emphasized procedures and high-technology, often at the expense of the basics.  So it should not be s surprise that Reuters just reported,

Nurses, the frontline care providers in U.S. hospitals, say they are untrained and unprepared to handle patients arriving in their hospital emergency departments infected with Ebola.

Many say they have gone to hospital managers, seeking training on how to best care for patients and protect themselves and their families from contracting the deadly disease, which has so far killed at least 3,338 people in the deadliest outbreak on record.

Furthermore, using as an example Medstar Washington Hospital Center, the largest hospital in Washington, DC,

Nurses argue that inadequate preparation could increase the chances of spreading Ebola if hospital staff fail to recognize a patient coming through their doors, or if personnel are not informed about how to properly protect themselves.

At Medstar, the issue of Ebola training came up at the bargaining table during contract negotiations.

‘A lot of staff feel they aren’t adequately trained,’ said [Emergency Department nurse Micker] Samios, whose job is to greet patients in the emergency department and do an initial assessment of their condition.

So Young Pak, a spokeswoman for the hospital, said it has been rolling out training since July ‘in the Emergency Department and elsewhere, and communicating regularly with physicians, nurses and others throughout the hospital.’

Samios said she and other members of the emergency department staff were trained just last week on procedures to care for and recognize an Ebola patient, but not everyone was present for the training, and none of the other nursing or support staff were trained.

‘When an Ebola patient is admitted or goes to the intensive care unit, those nurses, those tech service associates are not trained,’ she said. ‘The X-ray tech who comes into the room to do the portable chest X-ray is not trained. The transporter who pushes the stretcher is not trained.’

If an Ebola patient becomes sick while being transported, ‘How do you clean the elevator?’

Nurses at hospitals across the country are asking similar questions.

A survey by National Nurses United of some 400 nurses in more than 200 hospitals in 25 states found that more than half (60 percent) said their hospital is not prepared to handle patients with Ebola, and more than 80 percent said their hospital has not communicated to them any policy regarding potential admission of patients infected by Ebola.

Another 30 percent said their hospital has insufficient supplies of eye protection and fluid-resistant gowns.

So up to now, it appears that in the state of Texas, and across the country, the preparedness of public health systems and of front-line hospitals to deal with Ebola is unclear.  This may be due to political cuts in funding of public agencies, a payment system that favors procedures and high-technology over basic care, and leadership by generic managers who prioritize making money short-term over less financially advantageous priorities like preparedness for epidemics.  

Summary

Thus again there is reason to fear that our commercialized health care system run by generic managers, and our neglected public health system scorned because it is not “business-like” may not be fully up to the task of containing Ebola.  Again, hopefully this too will pass, without too many casualties.  However, one, maybe the only silver lining in the dark clouds of the Ebola crisis seem to be its capacity to challenge the pompous certainty by those invested in the status quo that we have the best health care system in the world.

The Ebola crisis should, again, lead to serious reflection on true health care reform, reform that would address concentration and abuse of power, reform that would enable leadership of health care by  well-informed people who are devoted to patients’ and the public’s health, who are honest and ethical, who are willing to be held accountable, and would shrink the size and power of individual health care organizations to make them truly responsive to patients’ health care needs and the public’s health needs. 

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68 comments

  1. The Infamous Oregon Lawhobbit

    All well and good, quite possibly – even probably – correct.

    But.

    Which of those non-mediocre, non-commercialized, health care systems in the rest of the world has brought forth an Ebola vaccine or cure?

      1. Guy

        Yves Smith’s missive shows the timeless correctness of Daniel De Leon’s adage that “Commercialism [capitalism] destroys all that it touches [including medicine].”

        Persevere
        Guy

    1. dw

      which only brings up the point. the US has the most drug companies, and seemingly, most other countries dont invest much in new drugs either, mainly cause they cant afford too. and since they seem to have found a way to control the cost of health care (drugs,etc) business doesnt see this as a way to make more money.

      its also not odd that we dont have an Ebola vaccine, nor do we have lots of others, because they just dont make money.

      1. Peppsi

        Speaking as a person with friends inside those businesses, profit motive is only part of the problem. A larger problem is systemic fraud in trials from animal models all the way to real live humans. If an ebola vaccine came out there would be a good chance of it doing not much at all.

        And I don’t mean that in an autism truther way, just a, ‘results are fudged to get drugs through testing and to market’ way.

        1. McMike

          I do not understand your caveat.

          You are willing to admit that trials are routinely falsified. How can you then be confident that denials about possible side effects are not falsified as well?

        2. Greg

          We’re also seeing new evidence that Statins and SSRIs have side effects that cause diabetes in some folks. You may recall that they appeared in the eighties and were prescribed readily especially before going off patent.

    2. jgordon

      That’s largely beside the point. Appropriate public health practices would make the need for elaborate vaccines and medications largely unnecessary. America, being the “best in the world” that it is, has no problem allowing a festering underclass to brew various disease–which will then propagate to the wealthier people. You know, because wealthy people don’t cook their own food or clean their own houses typically.

      In the broad picture though, it’s probably a win-win for humanity as a species. A smaller population of idiots (speaking of consumption-loving westerners here) will inevitably engage in less profligate resource stripping, senseless consumption, and rampant pollution, simply by virtue of there being less of them. Which barring the required and radical paradigm shift, is probably the best way to extend the viability of humans not going extinct by another decade or two.

    3. susan the other

      Fortunately for the world, we have India. I like to think that they will come up with good vaccines against ebola as well as after-infection treatments and they will do it soon, before any profit-craven western pharma companies can push themselves away from the banquet.

      1. JeffC

        Unfortunately for the world, we have India. If ebola leaks into rural India, say five months from now when the numbers in west Africa are 100x what they are today (do the math) so that a little leakage goes a long way, heaven help us all. Mix ebola’s diarrhea with a culture of crapping in the open – many rural Indians regard an indoor dump as unsanitary – and weak infrastructure, and you have the makings of a disaster of potentially epic proportions.

        1. susan the other

          You could be right about India being ultra vulnerable. All the more reason for them to produce drugs and vaccines. It is amazing we sent in the army to quarantine west Africa. Not sure we could do that in India. Or if it will even work. Since they are now saying there is a good chance ebola has mutated to be contagious in aerosols, I’ve been wondering if weather currents could carry it. Freaking out here.

    4. different clue

      We could achieve an ebola stampout-burnout without any wonder drugs at all if we put a functional Great Berlin Wall of China around Ebolastan starting right now. Zero air travel out, zero train travel out,zero driving out permitted, mine whatever rivers and coastlines needed to keep carriers from swimming or canoeing or steamboating out.
      Send in help only on the condition that zero human departure from Ebolastan is accepted and acceded to as the price of getting that help. Keep up the travel ban sealoff in place until zero new ebola cases emerge anywhere in Ebolastan. And force the Ebolastanis to accept our help on our terms or see all help withdrawn
      and Ebolastan surrounded with impenetrable sealoff infrastructure.
      If certain depraved communities repeat their murder of health workers, seal those communities off internally within Greater Ebolastan and kill anyone trying to come out as nature is permitted to take its course in any village so evil as to again murder health workers who risked their own lives to help these communities.

      Politically incorrect? Nasty? Well either we want to stop ebola or we don’t. And by the way, expect such measures to be replicated within and against our own countries if SARS or MERS emerges here.

      1. ian

        Exactly.

        I honestly don’t get why non-essential air travel to infected areas hasn’t been curtailed yet. That would only require executive action.

      2. OldLion

        Dallas is part of Ebolastan now.

        I’m certain everybody there will accept this policy without discussion.
        Except, maybe, there are people there that have serious business to do, who matter.
        So except for those important people, you can start shooting.

        regards

        1. different clue

          Of course . . . the “important people” exemption. This is the way the plague spreads.

  2. evodevo

    The way viruses “morph”, other than point mutation, is to participate in exchanging genetic material (genes or parts of genes) with another individual virus, within ONE host – this is how flu viruses accomplish it (bird flu strains infecting a pig host, for instance). Probably not going to happen with Ebola. The hosts don’t live long enough to acquire more than one viral strain. Advancing to a higher level of virulence is always possible, but would have to happen in Africa, not here. I would be MUCH more concerned about a flu pandemic.

      1. bruno marr

        I’m definitely not proficient with the new comments system. It won’t allow me to either use the “link” html or embed it manually. So, go look at the first page of LATimes.com first page, right now.

        1. financial matters

          Is this the one http://www.latimes.com/nation/la-na-ebola-questions-20141007-story.html

          good article citing some excellent infectious disease trackers, CJ Peters, Michael Osterholm, Philip Russell.

          This seems like good advice

          “Skinner of the CDC, who cited the Peters-led study as the most extensive of Ebola’s transmissibility, said that while the evidence “is really overwhelming” that people are most at risk when they touch either those who are sick or such a person’s vomit, blood or diarrhea, “we can never say never” about spread through close-range coughing or sneezing.

          “I’m not going to sit here and say that if a person who is highly viremic … were to sneeze or cough right in the face of somebody who wasn’t protected, that we wouldn’t have a transmission,” Skinner said.”

          1. RUKidding

            Thanks for that disquieting news, which I had suspected, anyway. We keep hearing that Ebola is transmitted via exposure to bodily fluids. But what, specifically, does that entail? HIV/AIDs is transmitted via exposure to blood only (as far as I’m aware). Ebola sounds more contagious bc bodily fluids encompasses much more than blood.

            I have also heard reports on the radio making the very false claim that Ebola is not contagious by any means during the 14 to 21 day incubation period, but that is proving to be incorrect as well. It *may* not be AS contagious as when the disease actually manifests, but I did see a video cast (sorry; can’t remember where) of a Doc (allegedly a specialist) who claimed that Ebola *could* definitely be transmitted during the incubation period, particularly via sexual relations.

            My Q, though not answered by the Doc, was whether someone could *possibly* (might be slim chance) be infected by someone in incubation phase who coughs or sneezes directly onto someone else… as happens far too often.

            Don’t like to be Doom-Sayer or Debbie Downer, but… there’s a boatload of unanswered Q out there, plus an equal boatload of misinformation being spread in the corporate M$M, unfortunately. Makes it hard to tease out fact from fiction.

              1. skippy

                When it kills as many as malaria then you can start worrying.

                Skippy… till then Proudhon-eon “Tyranny of Infection” rage on!!!!

  3. Meadows

    Very informed article, thank you. What few spokespeople for the medical/pharma/insurance complex want to admit is that we have a mediocre system of two tiers. For the well off (well-insured) very good care is possible. For the less well-off (not insured) there is the Emergency Room, which any Emergency Room doctor in any hospital in USA will tell you is either overwhelmed now or soon to be overwhelmed to the point of collapse.

    Furthermore, USA has a very large permanent underclass that is family fractured, medical services bereft, and ignored by elites. Even a minor epidemic will open up our social schism to a fearsome airing of the truth over the myth.

    1. susan the other

      And ironically, we could solve that problem with free trade. Just bring in clinics from countries that actually know how to practice medicine and handle virulent epidemics. But I forgot… we do not have free trade.

  4. Benedict@Large

    In a nation where people (correctly) feel that financial devastation lurks behind every hospital visit, there can be no first line defense against pandemics.

    1. janie

      Financial devastation also lurks for those without sick leave. The infected ones will go to work, try the remedies in the medicine cabinet, then go to an urgent care facility. Refusal of ambulance and E.R. will be common, even for those with insurance.

      1. Cocomaan

        Financial devastation also lurks for those without sick leave.

        I think this needs to be taken a step further.

        The healthcare system may or may not be able to handle the disease. There’s a good case above for why it might not.

        But it will be the caring classes (as David Graeber talks about here) that do not have sick time to take, that will be most likely to spread it.

        Imagine, for example, the Liberian immigrant in Dallas that works at a steakhouse. She doesn’t have sick time. She barely has healthcare. But she needs to go to work to feed her kids, and will go to work until she drops.

        1. MyLessThanPrimeBeef

          What do we do with self-employed hot dog vendors all over our big cities and big sports stadiums?

      2. jrs

        Even with sick leave, everyone comes to work sick. They have used all their sick leave for “mental health” (not that I blame them, 2 weeks vaction all year isn’t much) or when the car breaks down or the plumber needs to come to the house. OR they think they are “too important” to take a sick day, someone might find out you aren’t that indespensible. Having 5 days sick leave doesn’t seem to do that much to solve the problem of everyone coming to work sick.

  5. Roaring Mouse

    I appreciate the viewpoint that the profit-motive is bad for healthcare outcomes, but the real discussion-worthy point here is a hospital’s process for killing viruses/bacteria/fungi that are shed by patients. I’m sure Yves is aware of the hospital acquired infection (HAI) penalties that have been embedded into the US healthcare reimbursement system. How Ebola is being transmitted to healthcare workers who are treating sufferers at 1st world healthcare facilities is a far more interesting question, in my opinion. Perhaps Yves has read the clinical study summaries from the literature suggesting Ebola is not transmissable through the air. I’d appreciate the links to these studies.

    1. jgordon

      yves et al at NC still have an annoying habit of putting too much faith in authority figures, when the intelligent course of action would be to assume that everyone in a position of authority is self-interested liar until it is proven beyond a shadow of a doubt that they are possibly somewhat honest.

      To whit: http://www.washingtonsblog.com/2014/10/cdc-forced-admit-ebola-might-spread-even-symptoms-coughing-sneezing.html

      In other words, CDC = utterly incompetent and/or liars. Why anyone puts stock in what they say is beyond me. If you have enough people in authority lying about disasters or potential disasters enough times, you would think that intelligent people would begin to suspect that there’s a trend there.

  6. impermanence

    The U.S. health care system is the best in the world if you understand it’s main purpose, which is creating profits. It’s been this way for three plus decades.

    1. TimR

      This article intrigues me, sounds just about plausible:

      http://activistteacher.blogspot.com/2011/11/is-establishment-medicine-injurious.html

      Abstract — Establishment medicine is sustained by a triad of core deceptions: (1) An apical lie by omission which does not admit that the predominant causal determinant of an individual’s health is the individual’s real and perceived place in the society’s dominance hierarchy, (2) the “voodoo lie” of the false scientific foundation of its professional practice which does not admit that most of medical research used to justify the recommended “treatments” is wrong and that consequently the “treatments” are ineffective at best, and (3) the dirty secret that establishment medicine (in North America) is itself the third leading cause of death, after cancer and cardiovascular failures for which medicine is of little use. All three core deceptions have been decisively exposed by leading-edge mainstream researchers whose works have had virtually no impact in reforming the profession.

      1. jrs

        predominant casual determinant is a strong claim. Of course it’s fairly well know that such factors effect people’s health, but I’d have to see all the links for predominant.

      2. jrs

        Of course various relaxation modalities like meditation etc. could be one way to counter some of the destructive effects on health and brain function of living in a society where the 99s serve the 1s.

        An individual solution? Yes well individual lives do matter even though we need social change.

  7. Vatch

    A related question is whether or not our commercialized healthcare system can contain drug resistant tuberculosis. The answer is pretty obvious: No! The tuberculosis bacterium is very robust and can survive a long time outside a human host. So all it takes is a few uninsured infected people coughing in a public place, and shazam! Everybody in the vicinity is at risk.

    Sleep well tonight.

    1. frosty zoom

      this is a real quote:

      “We had to make some tough decisions,” Sally Wellborn, Wal-Mart’s senior vice president of benefits, told The Associated Press.

      1. cwaltz

        And how coincidental that their “tough decisions” come at a time when Walmart was just reported to have entered as a middleman into the health insurance arena. They’re hoping to make a couple of bucks off of “advising” these folks via DirectHealth I’d bet. How nice that they have a pool of people to be their focus group and a revenue stream.

  8. susan the other

    This is just one of the critical confrontations between capitalism and the welfare of society. There will be many more to follow until we ring-fence the looney concept of profiteering.

    1. RUKidding

      Well, really, those who get Ebola should just stop slacking around, pull themselves up by their bootstraps and INVENT a cure for themselves (but refuse to share said cure with the other lazy freeloaders out there).

  9. RUKidding

    Good post & commentary. I snap off the radio every time I hear Obama say “best health care system in the World!!” Yes, ok, if you’re very rich. For the rest of us serfs, not so much, and here I am including peons such as myself who allegedly get “good health ins benefits.” Said benefits dwindling quickly, and the level of care seems dodgy these days. Never sure of what I might be exposed to in the doc’s office, labs, or what have you. How well are these places cleaned? Can they ever be cleaned adequately? Of course, WOE betide those who go to ER. That way lies madness, bedlam & lots of nasty contagious germs & diseases.

    Is it possible for the US “health care system” to handle an Ebola outbreak well? Yes. It’s possible and feasible, but do I think it will do a “good job”? NO. We’ve already seen the outcome in Dallas, where an overwhelmed ER made mistakes, didn’t communicate, and the community took overlong to respond. Multiply this by X number of new potential cases across the country and … hold onto your hats bc it’s likely to be a very very bumpy ride.

    I guess the mega-wealthy figure they can retreat to their heavily armed & guarded gated residences, possibly with their own on-site medical facilities. But as someone, above, said: who provides the serf services there? And are their slaves taken care of on-site or are they booted out of the castle-keep to get their “health care” at the ER??

    Time will tell. I don’t want to be an Ebola “chicken little,” myself, but everything that has and has not happened so far does not make feel particularly safe or sanguine.

  10. Pearl

    I am only sharing this idea in conjunction with this (excellent) post by Yves because I’m assuming that persons interested in epidemiology may read some of the comments from us down here in The Peanut Gallery.

    This has to do with the surveillance and early detection of novel virus and diseases that circulate in our midst.

    I came up with an idea during the 2009 Swine Flu (H1N1) outbreak that I still think has merit and I would like to share the idea here. I believe it could be a helpful, low-cost disease surveillance and monitoring tool.

    The background is just this. My daughter was an undergrad at UC Berkeley back in March of 2009, and she became terribly ill. (She’s always had sort of, what I have come to term, a “hystrionic” immune system; it seems to kick into high gear (high fever, high WBC count) at the very first sign of any microscopic “assault.”) But her experience in 2009 was different in that it wallopped her even worse than usual. I asked the E.R. doctors to let a culture grow out to see if it was some sort of flu. The doctors declined, saying that flu season was over.

    But I just knew it was the flu–and I thought it was a bad one.

    A week or so later the “first” H1N1 was discovered in the U.S. down in some CA cities that border Mexico. (Because, sensibly, our disease control surveillance system is set up to look more regularly for new diseases and illnesses in border areas.)

    But I will always believe that H1N1 was already in the U.S. by that time–and I believe my daughter had it (and helped to spread it) a couple of weeks prior to it’s “official welcome” to the U.S.

    I did some cursory research into the surveillance of disease and illness here in the U.S. and was surprised at how skimpy it is during “business as usual” times. (A skimpy funding thing.)

    I had always assumed that the CDC and/or NIH had a better feel for what was circulating in the general population at all times, and was surprised that there really isn’t a system of doing that until we’re a few weeks into the appearance of novel or seasonal virus. (Generally triggered by an increase in doctor and E.R. visits–which are then reported to the CDC, and then the CDC tracks, studies, and reports those spikes.)

    But if we were to get hit by something really novel and really nasty–wouldn’t it be nice to have a couple of additional weeks on the front end to prepare? Perhaps we could do this via the regular, broad-based monitoring of our healthy, asymptomatic (pre-symptomatic?) population.

    So, I propose that we set up a surveillance of what is circulating out there in the typical and “healthy” population via a similar system to that of jury duty.

    In fact, I was thinking that, literally, in the instance of a person being called to serve for jury duty–only to show up in the morning to explain why he/she cannot possibly serve on a jury (usually due to time constraints) he/she might be given an alternative manner in which he/she may fulfill his/her civic duty. Such a person, if willing, might be directed to a (nearby) location where he/she may elect instead, to give an anonymous vial of blood for the purpose of providing to the CDC / NIH access to a constant and random blood sampling from a typical, healthy, socio-economically, ethnically, and geographically diverse pool of citizenry.

    So. There it is. My idea-du-jour. And it’s free-of-charge. ( I never charge for any of my ideas–or advice.) :-)

    1. Code Name D

      Quite true. Let’s not forget that patient zero was discharged with antibiotics. Antibiotics do not work with any virus, even the flue. So why give it out at all? Supposedly they did take a blood sample to do a viral count and identification – with results that only came back AFTER patient zero was checked back into the emergency room with detoirating symptoms.

      I remember when I came down with the flue sever enough that I was hospitalized for a just under a week. When they relieced me, I had a final conversation with the doc who told me that they suspected the flue strain simply because of the severity and symptomology, but didn’t know for sure. What? Did know for sure? They didn’t bother to find out for sure?

      I know it’s not that simple. If you have a thousand patents all coming in with the same flue like symptoms at mostly the same time, it’s a fair bet they all have the same thing. You don’t need to test every one. But you do need to test at least a few of them. If you have the means to be certain – why just assume?

      And apparently it’s not that complicated. My vet can identify a number of common pathogens with a lab no larger than most people’s kitchens. He even showed me around and let me observe the work. To identify most Bactria, all you need is a q-tip, a Petri dish, a few hours in an incubator, and a decent microscope (helps to know what you are looking at of course.) Why aren’t hospitals doing this?

      1. Juneau

        Testing is important. I am reading that there are only a few national centers that can do Ebola testing (like CDC). Also, you have to be far along in the course of infection to have it picked up. I find it misleading that the authorities talk about “negative” test results in contacts early on for this reason-even people who have contracted the virus test negative early on.

        No one wants accurate case identification more than the “canaries in the coalmnes” of this outbreak-the clerks, cleanup people, doctors, nurses, and other workers who staff primary care, urgent care and ER’s here. They will be among first to get sick and die if we get further outbreaks here. Unfortunately testing is not available at the ready. This may be a real headache during flu season. And getting people to transport the samples is a whole other headache.

        BTW if any one wants to experiment on people to test a vaccine, I expect a lot of front line workers will line up for that one as this progresses.

  11. Synoia

    Thus from 1983 to 2000, the number of managers working in the US health care system grew 726%, while the number of physicians grew 39%,

    This contains a germ of the answer to the question I’ve pondered, due to the rise in health care costs.

    A significant portion of the extra money is going to administration, as are the extra costs of college education.

    1. cnchal

      Instead of just the doctors having fleets of Mercedes Benzes and BMWs, their overlord accountants have them too.

      I wonder what the bill will be for treating the Dallas Ebola patient? I suspect his bill will be in the $ tens of millions. Good for a fleet of Ferraris.

      The system is so top heavy with overhead, stepping on a thumbtack will topple it. Is Ebola that thumbtack?

  12. kevinearick

    Marriage vs. Feudalism (Civil Marriage)

    Not to worry; Putin will not escape the gravity of Family Law in Russia, with Chinese toilet paper, any more than America has, with Kissinger & Kids.

    It’s always a small and shrinking world in the empire, because its behavior, cutting off the top and attempting to force it in back of the FILO bankruptcy queue, with an ever-growing line of gatekeepers, growing ever-more arbitrary decisions, paid in an entitlement ponzi of debt against your children’s future, fails every time, whether it employs gold, paper, bits, or tulips, that which is neither rare nor necessary.

    The irrational market for humanism, adrift of any mooring but itself, can only abstract itself into self-relativity.

    In this latest episode, they have merely employed MAD programming as the ultimate scapegoat, and with trillions of lines of code as a sunk cost, begetting ever more code, they are lost again, in the recursion of creating emergencies as demand and responding to emergencies as supply, making everyone in the empire a firefighter, fighting their own fires.

    Artificial intelligence placed in the media lobotomized head of Fred Flintstone only treads water so long. Cognitive Science is an oxymoron, as anyone who was there at inception can tell you, but no great analysis is required.

    Professors give the entitled preference, to arbitrary answers to arbitrary tests, just like in grade school in the city. If you want an A, position yourself in the herd accordingly. If you want to learn something, go where the herd does not. The answer to economic mobility is not residing in the penthouse.

    A minority of parents accept the responsibility of forwarding past investments. The majority liquidates in their own favor, employing their own children, the children of others and the children of those 5000 miles away, and their foundation crumbles every time. The petrodollar is just the latest financial shoring to hide the decay.

    History tells you not to spend more than 10% of your time bathing in poison, to activate your immune system. The vast majority of that poison enters your mouth, from the mouth of another. Most of what you consume is acid. Keep your mouth clean, by bathing it with baking soda diluted in water. Use olive oil when you cook. And it doesn’t hurt to drink coconut milk. Your teeth are living derivatives. Language is no different.

    Practice position, discernment and perspective.

    Feudalism, in all its forms, is simply a counterweight to marriage. Marriage lives in many dimensions. All feudalists attempt to narrow marriage to one dimension, their own, destroying generational and sexual trust, replacing them with an ever-growing laundry list of those to be added to the already long list of civil marriage. Jesus didn’t have anything nice to say about feminism, rampant at the time, or any of the other isms making up humanism.

    Government is immoral by definition; it can only see the moment it lives in. Trusting it to do stupid is one thing; trusting it with your family is another. The ‘elites,’ on the bottom rung of the evolutionary ladder, don’t have the brain cells to hunt you down, and the critters they employ are only one rung up, headed toward the DNA churn pool, studying it. The advantage of University is not what they want to teach you, but seeing the empire personality event horizons in action, agendaism.

    There are two possibilities with metal fillings. They are going to crack your teeth, creating a chain reaction as your teeth shrink, or they are going to be pushed out, as your teeth grow to remove them. If you let things go too far, as parents often do for the sake of their children, you are better off getting dentures, rather than letting the dentist hack you and your children up, one tooth at a time, only to end with bad dentures.

    You don’t learn at University any more than you learn anything about someone on a date. You learn by finding passion, in yourself and another. The empire has been trying and failing to bottle marriage for 5000 years, and it’s still a waste of time.

  13. McMike

    You’ll note that most of the money being spent on Ebola right now is the taxpayer’s (via the CDC).

  14. David Lentini

    Excellent article. Having worked in biotech companies, I’ve experienced quite closely that special blend of arrogance and ignorance known as “professional management”. I’ve also seen it ruin many good law firms and tech companies as well.

    I’ve often wanted to chart the rise in the number of of business school graduates with the decline in our manufacturing and industrial R&D; I suspect the correlation would be pretty convincing. It seems to me that this sad state of affairs is the result of Frederick Taylor’s Big Lie known as “scientific management”, in which he convinced gullible Progressives and greedy investors that “management” was a science in its own right and that a set of basic principles were common to all businesses. These principles were sufficiently complex to be beyond the ken of the business owners and founders, especially the great industrialists. Thus were the business schools created.

    Of course, the only real expertise outside of various bromides and urban legends was in accounting, the one activity all businesses share . And so, our new race of professional managers did what they knew best—and what they realized could most intimidate. So, we have been stuck with ignorant dolts running our businesses like Dilbert’s PHB (Pointy Haired Boss). Since the PHBs usually can’t deal with the actual operations of their businesses, they arrange a reign of error and terror while picking up nice paychecks for themselves.

  15. Code Name D

    What I am worried about is if it should hit the preverbal fan, will Obama step in and take charge? Or will he become the spectator in chief as he did with the Gulf Oil Spill?

  16. Rosario

    Already said this a few days ago, but a lack of a strong commons is the reason Ebola has become a global problem in the first place (Africa has been dealing with it and its more destructive distant cousin HIV for decades). Thanks to the wealthy of the world most African nations are poorly managed and just plain poor despite the immense natural wealth of the continent and extremely advance primary education (many African schoolchildren are learning Calculus by 10th grade). An entire continent of modern day plantations, all with absentee landowners and their petite bourgeoisie overseers. Our brimming resources may just save us in the USA, though I can’t speak much for our “reasoned” planning or ethical bearings.

  17. Lambert Strether

    National Nurses United is hot. They get it. This one quote sums it up for me:

    If an Ebola patient becomes sick while being transported, ‘How do you clean the elevator?’

    That’s bound to happen. Just because the generic managers sent a fraction of the staff to some PowerPoint presentation (no doubt prepared by some cozy “creative” class executive crony) does not mean the medical problems have been addressed.

  18. ian

    I understand the desire to not appear to be panicking, but speaking as an engineer, I’ve seen a lot of the same kind of stuff about nuclear reactors We’re assured by “experts” that bad stuff really can’t happen and that all contingencies have been thought of and taken care of.
    And yet, we have Fukushima.
    So given modern air travel and a seeming lack of interest in restricting non-essential travel to infected areas, and the fact that I live in a major metropolitan area – yes, it makes me pretty nervous.

  19. BondsOfSeel

    I too think our public healthcare system would not fare well under the strain of Ebola. Nurses and doctors can quit and simply walk off. Not to mention the piecemeal approach to every other disease… success at dealing with Ebola would be spotty at best.

    As for the risk of it happening? You said, “While the mortality rate is high, it’s not all that infectious. You are still more at risk from dying by virtue of driving (if you drive) than you are of dying from Ebola or terrorism.”

    That’s only because Ebola is not endemic to your region. You chances of dying from Ebola are greater in Liberia than from driving or terrorism…. and it’s growing exponentially which neither of the other are. To calculate the true risk, you have to calculate the risk of if spreading to your location * the odds of transmission in your area * the odds in an endemic area. It’s already traveled to Dallas, so it can happen. And as I mentioned, it’s growing exponentially. So, while that risk is small… it’s a small number growing exponentially.

    As for the morbidity of Ebola… compare it to other diseases. Yes… it’s not as contagious as the flu but much more than HIV. It’s much closer to say smallpox. … which is less scary since we have a vaccine. Yes, smallpox is very contagious, but if nurses in Spain using infection control are susceptible, it’s hard to argue it’s not virulent.

    P.S. I’d wait 23 days to see if it’s actually contained in Dallas.

  20. Tatanya

    And given that the government is not being truthful. One commenter on ZH quoted an opinion piece from AlbanyHerald.com I found insightful:

    “In the case of Ebola, our leaders want us to remain unconcerned. They have it under control, they say. And yet infected people keep popping up. Not to worry, they say…. Former ABC News anchor Ted Koppel once said: “Our society finds truth too strong a medicine to digest undiluted. In its purest form, truth is not a polite tap on the shoulder. It is a howling reproach.”
    Our leaders underestimate the ability and desire of the public to respond to the truth with sober minds. We can handle the truth, if our government will only tell it to us.”

    http://www.albanyherald.com/news/2014/oct/07/cal-thomas-isis-ebola-americans-can-handle-truth/

  21. EoinW

    Incompetence may be the safe assumption to make for what’s going on. I don’t discount it. Nevertheless one can’t help but connect the Ebola dots with the economic collapse dots and see this as a Black Swan event. If the natural response to dealing with an epidemic is isolation then why, months later, is direct travel to and from west Africa still being allowed? Can’t help but wonder if they want Ebola here. Meanwhile up in Canada, all the monkeys in the zoo can do is argue about our next undeclared war of choice and who is to be bombed and if Canada should be active or just the #1 cheerleader. It’s like they’ve never heard of Ebola. No travel advisories for Canadians going stateside, no increased screening at border crossings(whatever that might mean, yet our leaders don’t even feel compelled to go through the motions) no warnings to hospitals to watch out for potential cases. It’s as if six flights do not arrive in Toronto from Dallas every day. Everyone safely in the Matrix. Just ignore it and it doesn’t exist.

    Is this the way to end the economy and the bankers avoid the blame for the collapse? Yes the politicians will be vilified either way, but they’ll be richly rewarded by their financial backers. To be more sinister: is this the Moonraker Option, as in the James Bond movie? I wonder this while they flirt with Russia and nuclear war. No question that in such a war or a pandemic our 1% are best positioned to survive it – especially if they know it’s coming. Is Ebola in the West tolerable so long as it only claims 99% of the population? After all, had the bubonic plague hit France in 1788 there would not have been a revolution.

    Farfetched thinking, of course it is. However the key is that I and likely many others think so little of the people running our societies that we’d even entertain such ideas.

  22. Tatanya

    “Farfetched thinking?” Conspiracy theory? Perhaps, but I find it impossible to dismiss.

    “Conspiracy theory” is a term that at once strikes fear and anxiety in the hearts of most every public figure, particularly journalists and academics. Since the 1960s the label has become a disciplinary device that has been overwhelmingly effective in defining certain events off limits to inquiry or debate. Especially in the United States raising legitimate questions about dubious official narratives destined to inform public opinion (and thereby public policy) is a major thought crime that must be cauterized from the public psyche at all costs.”
    http://www.globalresearch.ca/conspiracy-theory-foundations-of-a-weaponized-term/5319708

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